Complex PTSD (CPTSD) and Dissociation – An Unrecognized Problem in Psychotherapy
In order to understand this complicated phenomenon we call dissociation (and specifically “pathological dissociation” it is necessary to understand where and why it develops. This condition is part of a syndrome called Complex PTSD. Before we can really understand where it fits in, I need to describe the differences in people who present in a therapist’s office with PTSD. By the way, PTSD is in my humble opinion (and many others) as a dissociative phenomenon, and should not be classified as an anxiety disorder.
Many times potential clients will start treatment with me saying that the last 5 therapists they had were nice people, but not quite helpful. Often these people suffer from Post Traumatic Stress Disorder of a different kind, called Complex PTSD (or CPTSD).
Let me explain some differences between PTSD and Complex PTSD (CPTSD). When the World Trade Center was hit on 9/11 2001, there were scores of people calling me in crisis. Some had been there, or had been close by; some had lost loved ones. By and large, these people were pretty well put together before this national tragedy. Many came from secure homes as children; most were married and had productive jobs.
These people are usually high functioning in their lives. Yet, after experiencing an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. Their response involved intense fear, helplessness or horror. (DSM 4 – TR 2000). They were quite “freaked out,” as we say in the vernacular.
Mental health professionals will easily recognize the aforementioned as the “A” criterion for PTSD. They will also suffer from intrusive and distressing recollections of the event, sometimes flashbacks, nightmares, and psychological and physical reactivity to anything that reminds them of their traumatic experience. Then there are a whole symptom complex of avoidant and hyperarousal symptoms.
Sounds pretty dire, doesn’t it? Well, these people can heal from this traumatic event without too much of a problem. I treated many of them with Eye Movement Desensitization and Reprocessing or EMDR. Treatment was usually pretty brief, and almost always successful.
EMDR is an “evidence based form of trauma psychotherapy that has been accepted worldwide as being highly effective in these cases. It has been researched by many mental health professionals and has consistently given the highest ratings by various organizations including the International Society for Traumatic Stress Studies, or (ISTSS); the Department of Defense and Veterans Affairs, to name a few reputable organizations.
That’s all well and good, but these problems pale by comparison when we talk about CPTSD. This form of trauma usually starts in early childhood and is characterized by harmful and persistent emotional, physical and sexual abuse. Courtois and Ford 2010) have edited one of the definitive text books on the subject. In chapter two Julian Ford describes the differences in brain development of children who have grown up in secure vs. abusive households.
In a secure and loving household children neurologically develop a “learning brain,” while those who have grown up in abusive households develop a “survival brain.”
“The learning brain is engaged in exploration (i.e., the acquisition of new knowledge and neuronal/synaptic (a end point of a brain cell called a neuron) connections… The survival brain seeks to anticipate, prevent, or protect against the damage caused by actual dangers, driven and reinforced by a search to identify threats, and an attempt to mobilize and conserve bodily resources in the service of this vigilance and defensive adjustments to maintain bodily functioning (Ford, Chapter 2 p. 32).
How is Pathological Dissociation a Part of CPTSD?
In order to begin to understand this phenomenon it is useful to first understand the syndrome of CPTSD. It characterized by:
•Affect Dysregulation (not being able to regulate one’s emotions)
•Alterations of Consciousness (The code name for pathological dissociation)
•Somatization (the development of many physical problems that multiple physicians cannot find an organic origin to)
•Loss of Systems of Meaning.
As stated, dissociation is related to the Alterations of Consciousness – While some think that this means only the “absence of,” it could also indicate the “presence of” (as in the “A” criterion of PTSD. Still with me?)
Identifying features of a dissociative disorder may go unrecognized. Why is that? I believe that the problem starts with many clinicians lacking the proper education in being able to identify dissociative phenomenon.
It’s important to realize that dissociation is on a continuum from something we all do, such as daydreaming, and other forms of absorption, to the more pathological disorders of dissociative amnesia, all the way to Dissociative Identity Disorder, or what lay people still call multiple personality disorder (yes, it exists, though there are some in the mental health field who claim that this is a made up problem, concocted by clinician and client. Let’s first look at this continuum.
The Adaptive to Maladaptive Continuum:
Here are some common forms that most of us experience.
•Forms of Forgetting,
Cross Cultural Perspectives need to be taken into account – such as altered states of consciousness; non possession trance, or shamanic rituals, soul journeys, spirit channeling. They all need to be taken into account in order to understand what part of dissociation is part of a culture, such as some primitive rituals in South America, Africa, and other countries, and what is pathological.
Here is where we start to find forms of pathological dissociation:
•Shock/Peritraumatic Dissociation (dissociation at the time of a trauma)
•ASD (or Acute Stress Disorder)/PTSD/CPTSD
•Depersonalization and Derealization
•Dissociative Identity Disorder
The Taxon/Epidemiological Model of Dissociation:
•Dissociation Classified by Symptoms of:
•DDNOS (Dissociative Disorders Not Otherwise Specified)
•DID (Dissociative Identity Disorder)
Elizabeth Howell in her excellent book, The Dissociative Mind, defines pathological dissociation as – “a separation of mental and experiential contents that would normally be connected.” (Howell 2005).
The BASK Model of Dissociation (Braun 1998) breaks down dissociation as a fragmentation of:
- B = Behavior
- A = Affect (or emotions)
- S = Sensations (whether present or absent)
- K = Knowledge
•According to Frank Putnam of NIMH (1997), “there is a failure of integration of ideas, information, affects and experience.”
All definitions bring a wealth of information to the table.
In the most general form, pathological dissociation has also been characterized as:
•Psychologically defensive, or organismic and automatic response to imminent danger (remember the survival brain I quoted Ford on earlier in this article?)
•The concept can be used as a verb when describing dissociative processes, such as when a person looks at themselves while experiencing themselves as not in their body.
It can be used as a noun, as in Dissociative Amnesia when someone cannot remember considerable blocks of time, while NOT under the influence of mind altering drugs or alcohol. I’ve had clients who tell me that they can not remember anything before the age of 12 (and they are only 32).
One of the problems with the concept is that there are so many definitions and disputes that the concept is in danger of losing its meaning.
•van der Kolk and Fisler (1996) describe PTSD (a type of dissociative experience), as involving “a unique combination of learned conditioning, problems modulating arousal, and shattered meaning propositions (as in a case where a priest sexually abuses an alter boy; there is often a loss of a religious system of meaning).
•Shalev (1995) proposed that this complexity is best understood as the co-occurence of several interlocking pathogenic processes:
•- an alteration of neurobiological processes involving stimulus discrimination.
• -the acquisition of a conditioned fear response to trauma related stimuli.
• altered schemata and social apprehension.
People who suffer from dissociative disorders are in a terrible bind.
•Because the roots of their relational traumas lie deep within their early childhood experiences, they often manifest strong dependency needs combined with a deep distrust of other people.
The way they perceive others is categorically different from other people.
Let me give you an easy example:
•When you see friends at a conference whom you haven’t seen for a year, often you will give them a hug. You or they won’t ask for one; you just “know” that it is fine.
•This example is part of what Lyons-Ruth (1998) calls “Implied Relational Knowing.” (IRK)
•Now take a patient from your population who has complex PTSD starting in infancy or early childhood.
•What is their “IRK”?
•”"People will hurt me; even the ones who seem to be nice at the beginning” (think of grooming behaviors of pedophiles).
•These patients will have a hard time trusting, and it will take a while to develop a therapeutic alliance. They will test their therapist to prove over and over again that he/she is worthy of their trust, and will actively search for signs that they are being fooled again.
•Many times these poor souls will be caught between their dependency needs, and their fear of harm.
van der Hart et. al have written beautifully about this dilemma in their text, The Haunted Self, (2006) in their chapter “Overcoming the Phobia of Attachment and Attachment Loss to the Therapist;” and Kathy Steele et. al(2001,) “Dependency in the treatment of complex ptsd and dissociative disorders,
•Davies and Frawley (1994) when the write about the idealized omnipotent rescuer and the entitled child.
•This dilemma was noted by Pierre Janet, a contemporary of Sigmund Freud’s.
•He was clear that there was a special need for the patient to feel safe with the therapist.
•He considered this alliance indispensible for any therapy to succeed with dissociative disordered patients.
•However, he recognized that forming this bond was fraught with difficulty.
•He observed that the patient was prone to idealization of the therapist.
•This idealization if not carefully managed could develop into an intense “somnambulistic passion.” (van der Hart, Brown, and van der Kolk 1989).
•While he called this idealization “rapport” we would call it transference today.
•Both Freud and Janet considered transference both a necessity and a resistance for a cure
•While Freud was better known for the concept of transference and repression, it was actually Janet who originated this idea.
Here are some other facts:
•There is a higher prevalence of undiagnosed dissociative disorders in clinical populations.
•There is a high cost to the patient, therapist and society for not adequately finishing the first phase of Janet’s phase oriented approach (which has also been known as the Consensual Model of Trauma Treatment).
•The first phase is stabilization, symptom oriented treatment and preparation for trauma work.
•If a therapist moved too quickly into the second phase which Janet called the liquidation of traumatic memories, too many negative outcomes could result.
•During the first phase it is necessary to stablize affect dysregulation. (A point made by Dr. Alan Schore 1994, 2003a, 2003b).
Treatment of dissociative disorders:
•It is crucial to be able to tell when a patient was not ready to even talk in depth about their traumatic histories
•To try to encourage this, as a means of shortening treatment, is a way of ensuring re-traumatization.
•When a patient seems to be having trouble telling a coherent narrative, the therapist needs to let the patient know that they can take as much time as needed, and that the therapist would be happy to teach stabilization and symptom relief strategies to the patient first.
•There are many signs and symptoms that the therapist needs to be aware of even before administering the Dissociative Experience Scale (DES).
•A history of years of unsuccessful therapy (Kluft 1985; Putnam et. al. 1986).
•The client comes to treatment with a number of varying diagnoses; none which have been successfully treated.
•The patient may have a history many in patient hospitalizations with multiple diagnoses over the years.
•The client reports intrusive thoughts, flashbacks, and nightmares.
•They may evidence periods of “spacing out” and forgetting what they were saying during an evaluation.
•The patient may report not feeling like themselves (perhaps they see themselves as bigger or smaller).
•They may report that surroundings that are known to them look somehow “different.” or;
•They may report looking in the mirror and not recognizing themselves. (de-realization)
•They may report having experiences of floating alongside their bodies (depersonalization).
•They may report that their daily environment seems dreamlike as if they were walking in a fog.
•They may report have memory lapses, i.e not recalling how they got to the shopping mall.
•Finding items at home that seem unfamiliar to them; not being able to remember ever buying them.
•In tertiary dissociation (DID) the client may report hearing strange voices coming frominside their heads.
•Experiencing “made feelings” i.e. feelings that come out of the blue, without having a logical way of explaining them.
•Having “made” thoughts and behaviors that they cannot identify as their own.
•Ross et. al. reports that DID patients have more first rank Schneiderian symptoms than schizophrenics.
•The DID patient, in contrast to the schizophrenic will usually demonstrate a full range of affect, whereas the schizophrenic patient will suffer from a blunted affect.
•Putnam (1989) reports that DID patients will evidence a preponderance of somatic symptoms, and will report:
•Intractable headaches not relieved by over the counter analgesics.
•Physical complaints that cannot be accounted for by competent physical examinations and tests. (These may be “somatic memories”)
•Sleep disturbances (Lowenstein 1991) are common with nightmares and sleep walking reported.
•Many DID patients may present with what they believe to be depression.
•Frequently there is a history of suicide ideation, or suicide attempts.
•These vast array of symptoms which must be asked about during an evaluation make it imperative to complete a DES on all patients where any of these symptoms are suspected.
If many of these symptoms appear familiar to you, it is best to call a therapist trained in diagnosing and treating pathological dissociation. An organization that supports the evolution of research and clinical practice of dissociative disorders is the International Society for the Study of Trauma and Dissociation (or ISSTD).
What you can do before and during the treatment of dissociation. I am indebted to a fine psychotherapist, Dr. Patti Levin for the following suggestions:
HELPFUL COPING STRATEGIES: If a person comes in for an evaluation and they do not have basic coping skills, here are a partial list of things they need to do before the reprocessing phases:
- mobilize support system — reach out and connect with others, especially those who may have shared the stressful event
- talk about the traumatic experience
- hard exercise like jogging, aerobics, bicycling, walking
- relaxation exercise like yoga, stretching, massage
- prayer and/or meditation
- hot baths
- music and art
- maintain balanced diet and sleep cycle as much as possible
- avoid overusing stimulants like caffeine, sugar, nicotine
- committment to something personally meaningful and important every day
- hug those you love: hugging releases endogenous opioids, the body’s natural pain-killer — now you know why it can feel so good!
- eat warm turkey, boiled onions, baked potatoes, cream-based soups — these warm foods are tryptophane activators which help you feel tired but good (like after Thanksgiving dinner)
- pro-active response toward personal/community safety: organize or do something socially active
- write about your experience — in detail, just for yourself or to share with others
People are usually surprised that reactions to trauma last longer than expected. It may take weeks, months, and in some cases, years, to regain equalibrium. Many people will get through this period on their own, with the help and support of family and friends. But too often friends and family push to “get over it” before you’re ready, or encourage feeling sorry for or trying to understand the perpetrator. Remind them that such responses are not helpful for recovery right now. Many people find that individual, group, or family counseling is helpful. Either way, the key word is ATTACHMENT — ask for help, support, understanding, and opportunities to talk.
The Chinese character for crisis is a combination of two words — danger and opportunity. Hardly anyone would choose to be traumatized as a vehicle for growth. Yet our experience shows that people are incredibly resilient, and the worst traumas and crises can become enabling, empowering transformations.
While these are excellent suggestions, I strongly urge anyone who believes that they may be suffering from a dissociative disorder to contact a competent trauma therapist trained in treating these conditions.
Braun, Bennett G.,”The BASK Model of Dissociation”, Dissociation Vol I, No. 1, March 1988.
Courtois, C., and Ford, J., eds. (2010) Treating complex traumatic stress disorders: An evidence based guide. NY: Guilford
Davies, J., and Frawley, (1994) Treatment of survivors of childhood sexual abuse NY Guilford
Diagnostic and Statistical Manual of Mental Disorders (DSM – IV- TR) Fourth Edition (2000) Arlington VA: American Psychiatric Association
Howell, E., (2005) The dissociative mind, NJ The Analytic Press
Foa, E., Keane, T. M., Friedman, M., J., Cohen, J., A., (2009) Effective treatments for ptsd: Practice guidelines from the International Society for Traumatic Stress Studies. NY: Guilford
Kluft, R. (1985) Childhood antecedents of multiple personality. Arlington VA:
American Psychiatric Association.
Levin, P., (2000) Helpful Strategies for Patients With PTSD and Dissociation. Boston, (self published)
Lyons-Ruth, K., (1998) “Implicit relational knowing: Its role in development and psychoanalytic treatment” Infant Mental Heath J. V 19(3) 282-289
Putnam, F. W. (1997).Dissociation in Children and Adolescents New York: The Guilford Press.
Putnam, F. W., Guroff J, Silberman E, et al. (1986). The clinical phenomenology of MPD: review of 100 recent cases. Journal of Clinical Psychiatry, 47, 285-293.
Schore, A., (1994) Affect regulation and origin of the self, Lawrence Erlbaum Associates Inc., Hillsdale NJ
Schore, A., (2003) Affect dysregulation and disorders of the self, Norton, NY
Schore, A., (2003) Affect dysregulation and repair of the self. Norton NY
Shapiro F, (2001) Eye movement desensitization and reprocessing, Basic principles, protocols and procedures. New York: Guilford
Steele, K., et. al., (2001) Dependency in the treatment of complex posttraumatic stress disorder and dissociative disorders, J. of Trauma and Dissociation, 2 (4), pgs 79-166
van der Hart, Brown, P. & Van der Kolk, B.A. (1989). Pierre Janet’s treatment of
posttraumatic stress. Journal of Traumatic Stress, 2(4), 379-396
van der Hart, O., Steele, K., Ninjenhuis, E., (2006) The haunted self. NY Guilford
van der Kolk, B., and Fisler, R., Dissociation and the Fragmentary Nature of Traumatic Memories: Overview and Exploratory Study. Journal of Traumatic Stress, 1995, 8(4), 505-525
This case history gives the essence of the EMDR reprocessing (which is what EMDR is best known for. It is not intended as a teaching tool, or a way to have yourself try to practice EMDR without going through the Basic Training in EMDR Psychotherapy. It is intended to give the reader who may be somewhat familiar with EMDR a sense of the power of this form of psychotherapeutic treatment.
Before this case history, Greg and I had a number of History Taking Sessions (Phase One) and Preparation Sessions (Phases 2).
The following is a shortened version of Greg’s history, and part of a treatment session where Greg is able to make a significant change in his life.
How EMDR Can Help Mend a Broken Heart Presenting Problem: Generalized Anxiety Disorder
Greg is a 30 year old, single, Jewish social worker who lives in an apartment in a suburb of New York City. He presents with an anxiety disorder. He had two romantic break ups and believes that he is a failure at love and that he can never please a woman. He also doubts that he would be able to find a suitable wife. He reported a good relationship with his father; but no relationship with his mother. His parents have been divorced for several years. He has an older sister who he rarely speaks to. He has a strong social support network, consisting mostly of his male friends he played sports with, and male and female colleagues.
He informed me during history taking that there were a few childhood “issues” that might be related to his present day anxiety. Present day Target Scene: His fiancée telling him that she was breaking up with him. NC: I’m unlovable PC: I’m lovable VOC 3 Emotions: Anxiety, panic, sadness, anger SUD 7 Body: Chest pounding, butterflies in his stomach, and loose bowel movements On direct questioning he told me of the first time he felt this anxiety: He was 11 and playing shortstop on his little league team. He was the star of the team and “the apple of his father’s eye.” His father was the coach. His mother never came to the games. His friend Billy, who played third base, told him that he saw his mother with Greg’s father getting into Billy’s father’s car earlier that day. Billy’s mother was crippled and rarely went out. Greg remembers feeling upset when Billy told him that and he made two errors that day. His father was upset and yelled at him. Picture – My father yelling at me after the game. NC (Initially Greg said “There is something wrong with me” which when I asked him what that say about him he responded, “I’m unlovable”) PC I am lovable VOC 2 Emotions: Sadness, guilt, anxiety Body: Rapid heart rate, cramps in his stomach, and daily headaches that his doctor could not find a cause for. .
Processing on the “Touchstone Memory” Greg: I hated that he yelled at me Go with that: Greg: At least I had one parent I thought loved me: Go with that: Greg: My parents never did anything together, and I always thought if I could please my mother maybe she’d love me and my dad. Go with that: Greg: Wait a minute, I just thought of something I haven’t thought about in many years. My mother was very musical, and she made me play the clarinet. I hated it, but I did it for her. When I was 8 she came to my class music recital. I was very excited. When it was over I walked up to her and I thought she would say something nice, but she told me that she heard me playing many wrong notes. Holy s—- I was just 8 years old. I wasn’t Beethoven. There was no pleasing her. I’m pissed. Go with that: Greg: Now that I think about it, I’ve been dating women who are always critical or disappointed in me. Marsha (his ex-fiancee) told me that I’ll never make enough money for her to live the life she wants to. F— that. I’m good at what I do. It’s like when I was playing shortstop. I was really good; and I liked doing it.
Insights: He always dated women who would put him down. He was trying to please them in an attempt to get his mother’s love. He would do things they wanted because that was what he thought would make them love him, even if he didn’t like what he was doing (like going to her friends’ barbeques where all the other husbands made a lot more money than he did, and played golf at a private golf club every weekend; Greg didn’t like golf; wasn’t good at it; didn’t have the money for it, but tried to join this club and play with these guys he didn’t like because Marsha wanted him to.) His mother never thought that his father was good enough for her, and she had an extra marital affair. This was his mother’s problem. She was an unhappy woman because Greg’s father was a teacher and didn’t make a lot of money either. “I like what I do and don’t need to make a fortune of money, but I needs to date different women.
Greg started to date a nursery school teacher shortly after this session. They dated for nine months; got engaged and married. They’ve been happily married for 6 years now, and they have a 4 year old son. Greg sends me a Christmas card with the family picture every year, along with a short note thanking me for helping him find love.
This phase begins at the following session after any active trauma reprocessing. The clinician looks over the clients journal, noting any progress, and then both the client and clinician work together to process the next memory that is decided upon.
A crucial part of the reevaluation phase is to determine what progress the client is making from session to session. They may not be aware at first, but may tell you conversationally that something just doesn’t bother them as much. Also look for nightmares and perhaps other kinds of challenging experiences the person had during the week because that may indicate more dysfunctional memories coming up for the client implicitly.
Thank you for reading my blog series, I hope you’ve found this information helpful and interesting. If you are a licensed mental health professional, please look into taking my EMDR Training coming up this fall. More information is on this website, and I hope to see you there. Take care!
The phase occurs with much time to spare at the end of the therapy session, whether active trauma processing is complete or not. The client is then instructed in journaling and other exercises that will hep enhance the progress made in the session. The client should also be made aware of the clinician’s availability if he or she needs extra assistance in between sessions.
During the closure phase it’s crucial to spend 15 minutes to debrief the person from their experience. When the experience is incomplete, I find it help full to ask four questions:
- What was the most important part of the experience?
- What has been the most challenging part of the experience?
- What one lesson did you learn?
- What one action (or thought) are you willing to take to honor this experience?
The last phase of EMDR is coming up next, so please come back to read it.
This phase functions as another checkpoint to assess the completion of trauma processing with all its associational channels. With their target memory in mind, the client is instructed by the clinician to scan their bodies from head to toe to self assess for any residual trauma or associational links. When a sensation is notes, the client is to open his or her eyes and process that sensation. It is possible that old trauma links can be experienced on a sensory motor level. This informs the clinician that further trauma processing is necessary for the client. It is also possible that pleasant sensations will arise. In this case, sets of EM’s can enhance the “installed” lessons.
What I have seen during the body scan is that even tiny somatic activations can be evidence of traumatic experiences that have not been reprocessed. Also, sometimes when the activation is positive it may mean that more adaptive information processing is going on, and we need to support that.
Once the trauma is desensitized to a zero by the previous phase, the PC and VOC are assessed again. Unless the clinician assesses that there is more trauma present, the clinician installs the positive cognition until it reaches a seven at least twice. (On a side note, the term installation is a bit jarring; Instead I have come to call it “Linking to the Adaptive Perspective”).
In my experience during the installation phase, there is a really good check and balance that happens. If the target memory and the positive belief do not seem to be fully installed, it may be evidence of additional traumatic material that may have not been reprocessed.
Phase 4: Desensitization
This is the phase of active trauma processing for the events and associations with the events. It is the clients brain the does the healing through bilateral stimulation and dual attention. It is the clinicians job to “stay out of the way” as long as “the train is moving down the tracks”. Only when productive processing stops, an active intervention by the clinician is necessary. Dr. Shapiro named The Cognitive interweave, and it’s function is to link more adaptive neural networks to the dysfunctional networks which block the processing. This allows the clinician to reactivate the clients information processing abilities to continue to resolve the painful memory networks.
I’m always amazed at the variety of associations and responses that I see in clients during bilateral stimulation. Sometimes profound effects occur without much release of emotion whereas sometimes a person may release much emotion but may not change in their daily life. It is important to use my best clinical judgement in order to determine how to adjust this phase to each particular person.
Glad to have you continue on to read about the next phase!
Phase 3: Assessment
This phase is the beginning of active trauma work. The client and clinician carefully choose a memory to work on, and this target must be focused on clearly. As the picture and negative cognition of the memory are described, a trauma activation sequence begins. There are many accounts of client activation into “State Dependent Memory” which means that the learning that took place in that memory or “state” is better remember when the client is in a similar situation or “state”. This can occur during the first parts of this phase, proceeded by PC and VOC, followed by the triggered emotions, their intensity, and body location.
When a person is able to think of an image or a negative belief, the feelings and sensations that they start to have in association with their trauma are being activated. This is necessary so that we can desensitize the trauma. The client needs to pay attention to these sensations throughout this phase. Also, use a positive cognition during the procedural steps because thats the installation of hope.
Phase 4 coming soon, so remember to check back. Thank you!
Thanks for coming back for phase 2!
Phase 2: Preparation
The function of this phase is to test for Affect Tolerance, Body Awareness, as well as test out coping strategies such as the Safe Place exercise. The Safe Place exercise is an 8 phase process to ensure that a person in capable of shifting into a more comfortable state when they’re slightly upset. In testing all of these different aspects, the clinician tries to gauge the person’s ability to self soothe. It is also during this stage that the degree of dissociation of the client is assessed.
It is also possible that there will be a person whose level of function may require a bit more evaluation to prepare for the trauma processing that will begin in the next few phases. On the other hand, findings show that people with Complex PTSD may benefit from not having any extra preparation.
Another important part of this phase is to explain the future phases to the client, to make sure that they understand what to expect. The responsibilities and functions of all participants involved should be clearly explained. I think that EMDR is a co-participatory method, and clients should be actively aware of this throughout the process.
I had an interesting experience with a client during this preparatory phase 2 with the safe place exercise. I was treating a young woman, and when I installed her safe place with bilateral stimulation within the first 4 phases of the exercise, she started to get tearful. Her safe place, a lake by her summer camp, also held a memory of when her boyfriend broke up with her. We needed to change her safe place so there would be no negative associations.
Please check back soon for another blog about phase 3.
EMDR is a multimodal, multi phasic methodology of treatment specific to the reprocessing of traumatic stress. The idea of EMDR therapy is to awaken and reactivate the brain to heal from the traumatic experience. The aim is to release the stress of the event, allow the person to better function in the world, and to empower the person to live more happily and productively.
EMDR has 8 specific phases, each with it’s own important function.
Phase 1: Client History Taking and Treatment Planning- The function of this phase is to assess:
1 – symptoms of dysfunction as a result of the client’s trauma.
2 – the individual’s ability to function in the world.
3 – the client’s useful and dysfunctional manners to assess their strengthens and weaknesses.
4 – specific aspects of a the client’s life and mind including negative beliefs, goals, ego strengths, gaps in ego strength, physical health, as well his or her gender and cultural identity.
It is necessary to have an account of all of these things in order to make a thorough evaluation of the person’s unique issues. The Trauma Case Conceptualization Questionnaire allows the clinician to have a much wider and clearer picture of the person being treated.
A challenge that sometimes comes along with this phase is when I have a new client who can’t articulate their narrative coherently. This alerts me that they may have a sense of disorganization and that I may need to teach them coping strategies and self soothing strategies first, even though they’re tested for in the second phase.
The first phase is just one of 8 steps in the EMDR therapeutic process, so please check back for the following phases in future blogs.
As stated in the first blog in this series, PTSD is not the only type of disorder that can result from an extremely traumatic occurrence in a person’s life. Acute Stress Disorder is another. Essential features of this disorder are anxiety and dissociation.
With symptoms identical to PTSD, Acute Stress Disorder is very similar to PTSD. The defining factor is that with ASD, symptoms usually resolve within 4 weeks. (Have you ever been really upset for an entire week, and maybe thought you were depressed, but you started to feel like yourself again soon after? This is a relatable example that also illustrates the difference between PTSD and ASD). After those 4 weeks, the diagnosis may change to PTSD, or these symptoms may continue on in a sub-acute phase. This implies that symptoms are still present at times, but are not present enough to be considered a full-blown psychiatric syndrome.
The sub-acute phase may contain symptoms of:
- intrusive thoughts
- hyper arousal
These symptoms can last anywhere from a few days after the traumatic experience, to a lifetime.
When a trauma occurs in a person’s life that he or she is unable to process, the ability to cope radically diminishes. When the pain of that experience can not be tolerated, dysfunctional thinking patterns may emerge, which can potentially turn into dysfunctional behaviors, such as overeating. This is why EMDR therapy, and it’s 8 stages which will be discussed next in this blog series, is a great tool to help people who have experienced an awful event.
In this blog series, I am going to go into great detail about EMDR in terms of what it is, who could benefit from it, and the different stages of therapeutic process. In this first blog, I’d like to write about trauma. EMDR can greatly benefit traumatized patients and awaken memories that will allow them to move past those awful experiences, ensuring them a happier life.
Trauma is any event or occurrence that the brain cannot metabolize, preventing people from being able to learn from their experience. Instead, they continue to have negative feelings, and poor beliefs about themselves. Reminders of that event will cause additional pain not including the initial pain that the event caused, making them feel worse. This can often lead to depression, anxiety or substance abuse.
There are many different types of trauma that can exist in numerous forms. Do you think you’ve ever experienced a traumatic event? Trauma is not limited to a formal diagnosis of PTSD, and not everyone who experiences an abnormally awful event will develop PTSD, but perhaps the definition of post-traumatic stress disorder (PTSD) could be helpful. PTSD is the result of exposure to an situation that may involve direct personal experience, or witnessing an event that is not within the realm of expectable daily experience. This can range from physical, sexual and emotional abuse to experiences of war, terrorism, or natural disaster. No matter the experience that triggered it, PTSD is a formal diagnosis including symptoms of:
- Intrusive thoughts such as nightmares and flashbacks
- Avoidance behavior such as psychological amnesia and not wanting to think about accident or participate in previously pleasurable activities
- Hyperarousal such as difficulty falling asleep, irritability, and problems with concentration.
Another condition that people may develop after a traumatic exposure is Acute Stress Disorder. Please read my next blog which will go into much more detail about this other trauma disorder.
THE CLINICIAN SELF AWARENESS QUESTIONNAIRE IN EMDR v.5
Mark Dworkin CSW, LCSW
EMDR Institute Facilitator
EMDRIA Approved Consultant and Instructor
Private Practice , East Meadow NY
Purpose: To assist in raising awareness of what may be triggering you; to assess what may be coming from you and what may be coming from the client; to develop EMDR Relational Strategies . Sometimes problems may occur in Phase One when a client shares information that evokes negative arousal; or Phase Two when the client has trouble understanding the elements of preparation or “wants to get going” processing trauma prematurely; or Phase 3 when there is a problem structuring the Assessment piece. Sometimes client information may not evoke negative arousal until Phase 4 when the client is actively processing. Often times our triggers are from old memories. These memory(s) may be explicit; at other times implicit (somatosensory). Noticing these moments in yourself may aid you in continuing productive processing.
Instructions – Whenever an EMDR treatment session becomes problematic; consider this self-administered instrument when reflecting on this session.
How many times have you seen this client? _____ Gender M___ F___ Marital Status M D S W
Gender and ages_______________________________________________________
Occupation (of client)______________________
1) Is this the first time you have felt triggered by this client? Y__ N__
2) If “No”, is this the same issue that has triggered you previously with this client? Y__ N__
3) Do you get triggered by the same issue with other clients? Y__ N__
4) Have you ever been traumatized? Y__ N__ Could your old trauma be triggered? Y__ N__
5) Do you believe that you are struggling with Compassion Fatigue/Vicarious Traumatization/Secondary Traumatic Stress Y__ N__
6) Describe the Presenting Problem (or Present Day Referents)
7) What old trauma(s) are related to Question 6?
8) Describe what is triggering you with this client NOW. How are you triggered?
9) Why do you believe that you are being triggered NOW?
10) What makes this client unusually challenging for you NOW?
11) – What is it about this client’s “style of struggle” with their problem (i.e. externalizing, intellectualizing, substance abusing) that may trigger you NOW. Why NOW? (Describe)
12) – Describe this client’s “presentation style”(avoidant, aggressive, straightforward, shameful, guilt ridden, etc.)
13) What triggers you about their “style of struggle”, and their “presentation style”?
14) When you think of the problem you are experiencing with this client what picture comes to your mind NOW?
15) When you see this picture in your mind, what negative cognition do you get about yourself NOW?
16) When you link the picture with the negative cognition what unpleasant sensations do you experience right NOW? Where in your body do you experience these sensations?
17) When you picture the client in your mind’s eye, who does this client remind you of? (Check as many as fit)
a) Mom __
b) Dad __
c) Sibling __ (Which)________________
f) Relative____ (Which)_______________________
What old memories emerge? (Hint- Use Floatback Technique)
18) What negative cognitions go along with these old memories? When you link the picture of the most disturbing part of the memory with this negative cognition what feelings and sensations arise in you RIGHT NOW? Where do you feel these sensations in your body?
Feelings and Sensations________________________________
19) Does your client notice your getting triggered? Y__ N__; if yes, how?
20) What does your client do with their reactions to your reactions? (To do this, reconstruct a piece of process that became problematic between the two of you).
21) After examining this piece of process how would you NOW reconceptualize this treatment problem?
22) What relational strategy(s) can you develop NOW to overcome this problem?
(When this questionnaire is part of a workshop or study group you may have the option of processing this issue to possible closure, including debriefing. Consider using Zangwill’s Floatback Technique when stuck in the present without old memories available).
Present Day Referent (in the treatment moment):_____________________________________________
23) Based on your experiential work, how do you NOW reconceptualize this problem. How does this answer differ from question #21?
24) What relational strategy might you consider NOW to help work this problem out?
Dynamical systems(such as human beings) are called nonlinear because a small change in input can lead to a huge and unpredictable change in output. Think of the cognitive interweave in this context. We are attempting to actively intervene in order to connect a more adaptive neural network with a state dependent one. We are as parsimonious as possible, as to create the smallest interruption of the client’s processing. However, because our clients are non linear, and so are we, the question becomes raised, “ Does my intended intervention succeed at its task”. We are gratified when this happens because a “small change”, i.e. “What if this were your child” may create the necessary linkage, amplified by bilateral stimulation to reorder the client’s thinking and emotional “State of Mind” This is an awesome moment.
However, not all Cognitive Interweaves achieve this effect. Let’s go back to non linearity.
Part of this unpredictability is due to the content-dependent nature of the systems response. The unpredictability also stands, in part, from the fact that the system as a whole is inherently “noisy”; this means that there will be random activation is that may or may not be reinforced by encounters with the environment. Systems have both determinate (predictable) and indeterminate (unpredictable) features to their behavior.
Because of these features, small changes in microcomponents of the system may sometimes lead to large changes in the macro behavior of the organism, and sometime it wont.
There could be multiple explanations.
An interpersonal question to ask may be, “Did I miss something in my take of where this client was, in the moment”?.
If so, what got fixated in me at this moment?
What old state of mind might this situation be activating for me?
What am I experiencing in my body? Somatosensory cues are crucial in raising our awarenesses.
If I do not believe I am being activated, what might my interweave stir in my client?
Human beings are complex. Siegel examines how different mental processes are organized within a state of mind.
These states allow disparate activities of the brain to become a cohesive at a given moment in time. A single brain functions as a system that can be understood by examining the “theory of nonlinear dynamics of complex systems,” or, more briefly “complexity theory.” Complexity Theory has been (and is being) applied to a range an inanimate and living systems in an attempt to understand the often unpredictable but self organizing nature of complex clusters of entities functioning within a system. Siegel proposes how the laws of such complex systems can be applied not only to a single mind but to the functioning of two or more minds acting as a single system.
Dan Siegel’s and Mark Dworkin’s Terms that Assist EMDR Clinicians in Understanding EMDR From a Two Person Perspective
Alignment* – is one component of affect attunement, in which the state of one individual is altered to approximate that of the other member of the dyad.
Appraisal - Involves a complex web of evaluative mechanisms in which both external and internal factors play active roles. The specific nature of appraisal incorporates past experience of the stimulus, including the emotional and representational elements of memory; present context of the internal emotional state, and external social environment; elements of the stimulus, such as intensity and familiarity; and expectations for the future.
Attractor States* – are reinforced learning patterns with states of activation. An attractor state consists of the activity of each component of the system and a given point in time; with unfolding experience, especially with the presence of the value systems of the living brain. Certain states become more probable as they are engrained within the system. With repeated activation, these attractors states become more deeply engrained, and the states are remembered. According to Hebb’s Axiom (“neurons that fire together wire together”), the brain is more likely to activate this clustering of processes in the future as a cohesive state of mind. The mind has a self reinforcing quality to its organization, which serves as in the mechanism for such reinforcement repeated states of activation at critical early periods of development shape the structure of neural circuit, which then formed the functional basis for enduring patterns of states of mind within the individual. When an attractor state is activated, emotional, cognitive, and behavioral manifestations may appear and be directed to the clinician in session.
Attunement* – is the capacity to read signals (often nonverbal) that indicate the need for engagement or disengagement. Attuned communication involves the resonance of energy and information. This intimate collaborative communication may be with or without words. This need for nonverbal attunement persists throughout life. Attunement involves the alignment of states of mind in moments of engagement, during which affect is communicated with facial expression, vocalizations, body gestures, and eye contact. Attunement does not occur for every interaction.
Co-Regulation – The continuous interaction between client and clinician which keeps them attuned and aligned with each other so that the productive work of trauma processing, or resourcing can continue.
Countertransference* – is the activation of old mental models (or dysfunctional memory networks) and states of mind from the clinician’s relationships with important figures in the past.
Intersubjective – The continuous feedback loops between clinician and client based upon old mental models and states of mind from relationships with important figures in both participants pasts. The interface of reciprocally interacting worlds of experience.
Mental model* — with repeated experiences, the brain develops ways of evaluating and identifying current incoming stimuli comparing, and detecting similarities and differences across time and experiences. From these comparative processes, the brain makes generalized representations for repeated experiences encoded in divergent areas of the brain. These mental models create different “schemata”, or ways of experiencing and acting in the world.. Mental models are basic components of implicit memory helping the mind to seek out familiar objects or experiences and to know what to expect from the environment.
Mental State Resonance* – is the experience that happens when sensitivity to signals of attunement between client and clinician are occurring. This experience involves the intermittent alignment of “states of mind” in both parties. As two individual “states of mind” are brought into alignment this experience occurs in which each person is influencing and is being influenced by other. Productive trauma memory processing usually occurs in this state.
Mental time travel* — is a mental process which identifies experiences in the past, and compares them to current day stimuli. Mental time travel assists in the evaluative process of our bodies and minds, and how they affect the client’s present and future thinking and feeling. The stability of “states of mind” across time creates the self within the social world.
Transference - is the activation of old mental models (or dysfunctional memory networks) and states of mind from the client’s relationships with important figures in the past.